CEC Application Assistance & Enrollment Procedures 4 — Questions and Answers
Question 1: What is the primary difference between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) plan?
- HMOs always have lower deductibles than PPOs
- HMOs typically require referrals and restrict coverage to in-network providers, while PPOs offer more flexibility with out-of-network coverage (Correct answer)
- PPOs require a primary care physician designation; HMOs do not
- HMOs cover more services than PPOs under federal law
Correct answer: HMOs typically require referrals and restrict coverage to in-network providers, while PPOs offer more flexibility with out-of-network coverage
HMOs require members to use in-network providers and get referrals for specialists, whereas PPOs allow out-of-network care at a higher cost-sharing level.
Question 2: A consumer who missed open enrollment claims they qualify for an SEP because they recently got married. What documentation might be needed to verify this SEP?
- Birth certificate
- Proof of prior coverage termination
- Marriage certificate (Correct answer)
- Employer letter
Correct answer: Marriage certificate
Marriage is a qualifying life event triggering an SEP, and a marriage certificate is the standard documentation used to verify this event.
Question 3: Under the ACA, what is the maximum percentage of household income that a consumer at 300% FPL is generally expected to pay for a benchmark Silver plan premium after applying APTC?
- 0%
- A fixed percentage set by the ACA's affordability schedule for their income level (Correct answer)
- 50% of the premium
- The full premium with no subsidy
Correct answer: A fixed percentage set by the ACA's affordability schedule for their income level
The ACA establishes an affordability schedule where consumers pay a capped percentage of income for the benchmark plan, with the APTC covering the remainder.
Question 4: A consumer asks about enrolling their newborn in Marketplace coverage. What rule applies to newborns born to an enrolled parent?
- Newborns must wait until the next open enrollment period to be added
- Newborns are automatically enrolled under the parent's plan and have a 60-day SEP to be formally added or switched (Correct answer)
- Newborns are ineligible for Marketplace coverage until age 1
- Newborns require a separate application and premium payment immediately
Correct answer: Newborns are automatically enrolled under the parent's plan and have a 60-day SEP to be formally added or switched
A birth triggers a 60-day SEP, and newborns are generally covered under the parent's plan during this window until formally enrolled.
Question 5: When an enrollment counselor assists a consumer in selecting a plan, which of the following is the MOST appropriate guidance regarding network adequacy?
- Choose the plan with the lowest premium regardless of network
- Advise the consumer to verify that their preferred doctors and hospitals are in the plan's network before enrolling (Correct answer)
- All Marketplace plans have identical provider networks
- Network differences only apply to dental plans
Correct answer: Advise the consumer to verify that their preferred doctors and hospitals are in the plan's network before enrolling
Consumers should confirm that their preferred providers are in-network before enrolling to avoid unexpected out-of-network costs.
Question 6: A consumer who received APTC during the year reports a significant income increase when filing taxes. What is the likely outcome?
- The consumer receives a larger refund for the excess subsidies
- The consumer may need to repay some or all of the excess APTC received, subject to repayment caps for lower incomes (Correct answer)
- There is no financial consequence for income changes
- The IRS automatically adjusts the APTC without any consumer action
Correct answer: The consumer may need to repay some or all of the excess APTC received, subject to repayment caps for lower incomes
When final income exceeds the estimated amount, consumers must repay excess APTC on Form 8962, though repayment caps apply for incomes below 400% FPL.
Question 7: Which of the following scenarios would NOT qualify as a Special Enrollment Period trigger?
- Losing job-based health coverage
- Moving to a new ZIP code or county that offers different Marketplace plans
- Voluntarily canceling a current Marketplace plan because premiums seem high (Correct answer)
- Having a baby
Correct answer: Voluntarily canceling a current Marketplace plan because premiums seem high
Voluntarily dropping coverage without a qualifying life event does not trigger an SEP; consumers must wait for open enrollment unless a true qualifying event occurs.
CEC Application Assistance & Enrollment Procedures 4
What is the primary difference between a Health Maintenance Organization (HMO) and a Preferred Provider Organization (PPO) plan?